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Health Affairs Article: Americans Willing to Pursue Health Care Excellence for Some, While Tolerating the Deterioration of Care for Others

WASHINGTON, DCAs health care gobbles up an ever-larger
share of the U.S. economy, the inability or unwillingness to ensure equal access
to high-quality health care is fueling a widening rift between rich and poor
Americans, according to a study by the Center for Studying Health System Change
(HSC) published today as a Web-exclusive article in the journal Health Affairs.

"Increasingly, America is turning into a country of health care haves
and have nots, driven primarily by the type ofor lack ofhealth coverage people
have," said lead author Robert E. Hurley, Ph.D., an HSC senior consulting
researcher and associate professor at Virginia Commonwealth University. HSC
is a nonpartisan policy research organization funded principally by The Robert
Wood Johnson Foundation.

Many recent health care investments and initiatives are focused on affluent
communities and are accessible mainly to people with employer-based or Medicare
coverage, while access to basic care for people with Medicaid or no coverage
at all is worsening in the wake of stalled coverage expansions and service cuts,
according to the article.

"A clear hierarchy of access to care is emerging in many communitiesthere
is growing evidence that U.S. society is willing to tolerate almost limitless
access to care for some and deteriorating access to basic care for others,"
said Hoangmai H. Pham, M.D., M.P.H., an HSC senior researcher and study coauthor,
along with HSC Consulting Researcher Gary Claxton of the Kaiser Family Foundation.

Two perspectives written by Eric Book, chief medical officer of Blue Shield
of California, and Timothy Ferris and David Blumenthal of Harvard Medical School,
accompany the article. Book advocates universal coverage to address coverage
gaps, while Ferris and Blumenthal support strengthening safety net providers.

Other key findings of the HSC study include:

While the distribution of lower-income patients has long been skewed
toward certain providers, evidence suggests these lines of segregation are hardening,
driven largely by the dictates of geography and channeled in part through growing
disparities in access to physician care. Underlying this phenomenon is the interaction
of two major trends: 1) growth of investments by both hospital systems and physicians
in specialty services and relocated services, such as diagnostic testing from
inpatient to outpatient settings; 2) and the recent burst of hospital facility
expansions.

Hospital expansions in affluent areas have the potential to worsen
disparities when they reflect a differential investment of resources between
poorer and wealthier communities. Institutions serving poorer populations begin
with significant disadvantages, as they are less likely to have sufficient capital
or the financial health to obtain debt financing to invest in new building.

Hospitals and physicians are increasing specialization of medical
care, including acquiring and applying new diagnostic and treatment techniques
and technologies, in both full-service and freestanding facilities. Hospitals
are engaged in major construction initiatives after a decade-long lull in capital
expenditures. Some projects have been undertaken to upgrade facilities to make
them more suitable for providing state-of-the art-care at the level of contemporary
customerpatient and physicianexpectations. Other projects involve extending
services to new locations closer to more affluent and well-insured customers.

State and local budget shortfalls and resulting Medicaid payment freezes
and reductions have worsened access problems to key services like mental and
dental care, as well as many types of specialty care. Applying copayments, eliminating
benefits, and setting arbitrary limits on services is seen by some observers
as "cost-shirking" that leaves providers caring for these patients
in the position of either dropping them or absorbing the cost of their uncompensated
care.

### ###

The Center for Studying Health System Change is a nonpartisan policy research
organization committed to providing objective and timely research on the nations
changing health system to help inform policy makers and contribute to better
health care policy. HSC, based in Washington, D.C., is funded principally by
The Robert Wood Johnson Foundation and is affiliated with Mathematica Policy
Research, Inc.

Health Affairs, published by Project HOPE, is the leading journal of health
policy.